Transition Counselor (Medicaid)

Denver Regional Council of Governments•Denver, CO

3d•Onsite

About The Position

The Denver Regional Council of Governments (DRCOG) is seeking a Transition Counselor to provide in-reach counseling for older adults and adults with disabilities residing in skilled nursing facilities who wish to transition to community-based settings. This role involves assessing client needs, educating them about community living options, managing expectations, and providing information and referrals regarding Colorado's Medicaid Transition Services. The position requires maintaining client confidentiality, documenting interactions, and collaborating with facility staff and community providers. DRCOG is a visionary leader focused on addressing major regional issues like growth, development, transportation, and the needs of older adults, built on strong partnerships and a commitment to finding innovative solutions.

Requirements

Bachelor’s degree in gerontology, social work or related human services field.
One to three years of related human services experience.
Valid Colorado Driver’s License.
Access to an automobile or to substantively equivalent alternative transportation.
Knowledge of age and disability related issues and concerns of adults, their families and caregivers.
Knowledge of person-centered practices, including self-determination, informed choice, and autonomy.
Knowledge of tools for effective communication including active listening, engagement, and empathy.
Knowledge of aging and disability area networks and resources.
Knowledge of principles and applications of critical thinking and analysis.
Knowledge of best practices, trends and emerging technologies.
Knowledge of principles and practices of program administration and management.
Knowledge of principles and methods of qualitative and quantitative research.
Knowledge of record management principles.
Knowledge of applicable federal, state and local laws, codes, regulations (based on assignment).
Knowledge of customer service principles.
Knowledge of specialized equipment relevant to area of assignment.
Knowledge of modern office technology.
Skill in researching industry trends, solutions and best practices.
Skill in performing assessment of client situations to determine case management and/or emergency needs.
Skill in conducting interviews to determine client or program service needs and/or intervention.
Skill in gathering data, analyzing findings and applying logic and reason.
Skill in interpreting, monitoring and reporting information and statistics.
Skill in authoring original reports, documents and presentations.
Skill in compiling and sorting data and articulating issues and recommendations.
Skill in coordinating deadlines and prioritizing competing demands.
Skill in maintaining program or case information.
Skill in exercising confidentiality.
Skill in collaborating and facilitating communication with program stakeholders.
Skill in interpreting and applying applicable laws, codes, regulations and standards (based on assignment).
Skill in providing customer service.
Skill in utilizing a computer and relevant software applications.
Skill in utilizing communication and interpersonal skills as applied to interaction with coworkers, supervisors, the general public and others to sufficiently exchange or convey information and to receive work direction.
Familiarity with basic concepts of digital accessibility, including techniques for accessible writing, presenting, remote meetings, and document creation.

Responsibilities

Performs client interviews, intake and assessments to determine service needs and resource requirements.
Serves as an agency representative with other service providers to address service requirements, availability and needs assessment.
Makes resource referrals to both internal and external programs.
Provides client advocacy based on required situations.
Documents program eligibility status.
Determines case safety level, emergency status and/or need for crisis intervention or mandatory reporting.
Determines, develops, and communicates client service action/case plans.
Monitors and documents plan status and performs follow up on case services.
Coordinates the exchange of service information and service care provision with other agencies.
Assists in conflict or behavior management.
Assists in the resolution of disagreements among clients, families, systems and service providers.
Monitors client status.
Provides counseling and intervention support.
Conducts on-site client visits and performs needs assessment.
Determines crisis intervention needs.
Escalates case management supervision as required.
Prepares, documents and maintains case and/or program information.
Collects, manages and analyzes data to produce reports documenting program measures and outcomes.
Provides recommendations.
Ensures the maintenance of timely program or case activity tracking, reporting and applicable billing.
Provides training and community education for groups and individuals.
Researches and identifies community service needs.
Collaborates with stakeholders and makes program, process and community service recommendations.
Prepares and disseminates information.
Performs outreach for care improvement.
May be responsible for securing, monitoring and reporting special program funding.
Provides in-reach counseling for older adults and adults with disabilities who reside in skilled nursing facilities and desire to transition into a community-based setting.
Conducts an in-reach counseling assessment with interested clients at the skilled nursing facility.
Educates clients about options for moving into a community-based setting and managing expectations related to the transition process.
Enters individualized referrals into the State’s data system for referral to a transition coordination agency and to identify client’s preference to participate in future in-reach counseling conversations.
Provides information and referral to clients and skilled nursing facility staff regarding the State of Colorado’s Medicaid Transition Services benefit for clients with Medicaid non-Medicaid services available in the community to older adults and adults with disabilities.
Maintains confidentiality of client information as required by state and federal laws, regulations, and professional practice standards.
Provides skilled nursing home clients and staff with objective and accurate information on all aspects of Medicaid and non-Medicaid benefits.
Conducts training on Medicaid Transition Services and MDS Section Q for skilled nursing facility staff and community providers.
Documents all client interactions and tracking multiple attempts to reach clients or their decision-makers.